In Maryland and across the nation, the role of physicians in executionshas become an issueamong medical professionals and in the courts

In North Carolina, a physician monitored a condemned inmate's brain waves as the drugs that would bring death were about to be added to the IV. The doctor was prepared to direct executioners to inject more anesthesia if the prisoner remained conscious.

Doctors in Georgia have gradually taken on larger roles in state executions, starting intravenous lines when nurses could not and, on one occasion, even ordering a second dose of potassium chloride after a prisoner's heart did not stop.

In Maryland, a team of correctional officers, prison officials and hired nursing assistants and paramedics carries out executions. Although a doctor is present, her only role has been to pronounce death.

Across the nation, doctors are crossing a line that has existed for more than 2,000 years in the view of most medical professionals, violating an oath to do no harm to patients by participating in executions.

Even the limited role of declaring that a prisoner has died is prohibited by the American Medical Association and other professional organizations that have taken firm positions against any involvement by doctors and nurses in the administration of capital punishment.

Now, in a case challenging Maryland's lethal injection procedures, lawyers representing state prison officials and attorneys for death row inmate Vernon L. Evans Jr. are facing off in federal court over whether physicians and highly trained nurses are needed for Maryland's executions. Even the judge hearing the case has asked whether medical professionals who live by the Hippocratic Oath can be persuaded to help put a man to death.

Indeed, the question of whether physicians could or should participate in executions has become an issue in the long-running national death penalty debate, with opponents arguing that lethal injection procedures as currently carried out in many states by individuals with little or no medical training represent unconstitutionally cruel and unusual punishment.

The presumption has been that doctors don't participate. But, in death chambers across the country, some have.

"I had no qualms," one nurse, who started an IV in an inmate who was about to be put to death in a prison out West, told a surgeon and medical school professor who wrote an article about physician participation in executions for The New England Journal of Medicine. "If this is to be done correctly, if it is to be done at all, then I am the person to do it."

The nurse - like nearly everyone who has taken part in executions, whether in Maryland or elsewhere - remained anonymous. Of the 15 medical professionals Dr. Atul Gawande located for his article, only five agreed to speak to him, and only one allowed his name to be used.

That physician, Dr. Carlo Musso, compared his role in executions in Georgia to any other "end-of-life issue" that he faces in his practice of medicine, and said a condemned man is "no different from a patient dying of cancer - except his cancer is a court order."

"When we have a patient who can no longer survive his illness, we as physicians must ensure he has comfort," Musso, a death penalty opponent, was quoted as saying. He told Gawande that he had done nothing during the six executions in which he had participated but watch inmates' heart rhythms on a cardiac monitor to determine when the prisoners had died. Attempts to reach him for this article were unsuccessful.

But physicians who participate in executions - even just to pronounce death - do so in violation of many professional medical associations' codes of ethics.

Dr. Arthur Zitrin, a New York psychiatrist and clinical professor who has lodged complaints with medical licensing boards against the few doctors who have been publicly identified as execution participants, explained: "In the event that the condemned inmate is not dead, the obligation of the physician would be to say, `Get more drugs' or recommend that the execution process continue. ... The obligation of the physician would be to make a recommendation to kill a person. He's becoming an executioner, really."

Gawande, a Boston surgeon and Harvard Medical School professor who spent more than a year trying to find doctors and nurses who participate in executions for his New England Journal article, said in an interview that some agree to take part out of the belief that their involvement will help ensure that the lethal injection procedures are carried out as painlessly and humanely as possible.

According to Gawande's article, two doctors had become involved at the request of their patients, who happened to work at prisons where executions were performed. Another of the doctors told his wife about the job right away but could not bring himself to tell his children until they were adults. And one, after having to give a deposition in a court challenge to a lethal injection, came to work one day to find a sign on his clinic door that read, "The Killer Doctor."